ERECTOR SPINAE PLANE BLOCK AND OZONE THERAPY: THE INNOVATIVE ALLIANCE AGAINST CHRONIC DISCOGENIC BACK PAIN

S. Sorrenti¹, M. Ciuffreda¹, E. Pisello¹, L. Brugiaferri², A. Federici², C. Piangatelli³, D. Galante⁴ | ¹U.O.C. Anesthesia Resuscitation Pain Therapy, AST Ancona, Fabriano (AN); ²Residency School. Anesthesia, Resuscitation, Intensive and Pain Therapy, Università Politecnica delle Marche, Ancona; ³U.O.C. Anesthesia, Resuscitation Pain Therapy, Director, AST Ancona, Fabriano (AN); ⁴U.O.C. Anesthesia and Resuscitation, Director, Cerignola (FG)

INTRODUCTION
The Erector Spinae Plane (ESP) block is a relatively recent locoregional anesthesia technique, increasingly used not only in postoperative spine surgery but also in the management of various acute and chronic pain conditions. Its mechanism of action is still under investigation, but most hypotheses suggest an interfascial spread affecting the dorsal rami of spinal nerves, with possible anterior diffusion into the paravertebral space. Simultaneously, ozone therapy has long been applied in the treatment of chronic discogenic low back pain (DLBP), thanks to its anti-inflammatory, antioxidant, anti-edema, and analgesic effects. However, the integration of ozone into ultrasound-guided locoregional techniques is still rarely documented. Combining ESP block and ozone may offer a novel, minimally invasive approach for patients unresponsive to conventional treatments.
METHODS
We describe the case of a patient with a history of chronic DLBP and acute onset of left-sided lumbosciatica (NRS 8–9). MRI revealed a median-paramedian L4-L5 disc herniation and an extruded L5-S1 disc in the left preforaminal space, with caudal migration. Initial treatment with oral methylprednisolone led to only partial improvement. After a subsequent relapse, pain was successfully managed with slow-release diclofenac (NRS 0), but recurred after discontinuation (NRS 4–5) with sciatica-like features extending from the left gluteal region to the foot, worsened by movement and positive Lasègue sign. As the patient refused epidural corticosteroid injections and was unsuitable for long-term NSAID therapy, we proposed an ultrasound-guided ESP block combined with ozone. A convex probe and a 50 mm needle were used to perform a left L4-L5 ESP block, injecting 20 ml of ozone at a concentration of 40 mcg/ml.
RESULTS
In the two days following the first ESP block, the patient experienced significant pain relief (NRS 2–3). This was followed by a transient increase in symptoms (NRS 4–5), but further gradual improvement was reported two weeks later (NRS 2–3). A second identical ESP block was performed one month later, resulting in complete resolution of pain (NRS 0), which was maintained at follow-up without the need for further pharmacological therapy. No adverse events were observed.
CONCLUSIONS
This case highlights the potential role of combining ESP block and ozone therapy in the management of chronic DLBP, particularly when standard treatments are ineffective or contraindicated. ESP block offers a technically simple, ultrasound-guided solution with a favorable safety profile, while ozone enhances the anti-inflammatory and analgesic effect through its biological properties. Although literature on this specific combination is still limited, our experience suggests it may represent a valuable and innovative tool in pain management. Further clinical studies are needed to validate its efficacy and optimize treatment protocols.